Crenolanib combination therapy

ABSTRACT

The present invention includes methods for treating a proliferative disorder by blocking both PDGFR and VEGFR signaling comprising a therapeutically effective amount of crenolanib or salt in combination with a VEGF/VEGFR inhibitor that is not axitinib wherein the crenolanib, VEGF/VEGFR inhibitor that is not axitinib are provided at least one of sequentially or concomitantly, in a subject for use in the treatment of the proliferative disorder, wherein the subject is a human subject.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.16/713,935, filed Dec. 13, 2019, which claims priority to U.S.Provisional Application Ser. No. 62/779,128, filed Dec. 13, 2018, andU.S. Provisional Application Ser. No. 62/861,424, filed Jun. 14, 2019,the entire contents of each is incorporated herein by reference.

TECHNICAL FIELD OF THE INVENTION

This invention pertains to crenolanib, or salts thereof, and aninhibitor of a Vascular endothelial growth factor (VEGF) and/or aVascular endothelial growth factor receptor (VEGFR) that is not axitinib(VEGF/VEGFR), for the treatment of proliferative disorders, and to amethod of treatment of warm-blooded animals, preferably humans, in whicha therapeutically effective dose of crenolanib and a VEGF/VEGFRinhibitor that is not axitinib is administered to a subject sufferingfrom said disease or condition.

STATEMENT OF FEDERALLY FUNDED RESEARCH

Not applicable.

INCORPORATION-BY-REFERENCE OF MATERIALS FILED ON COMPACT DISC

Not applicable.

BACKGROUND OF THE INVENTION

Without limiting the scope of the invention, its background is describedin connection with cancer treatments and the use of novel combinationtherapies that include crenolanib.

On such combination therapy is taught in Michael, et al., “Phase Ibstudy of CP-868,596, a PDGFR inhibitor, combined with docetaxel with orwithout axitinib, a VEGFR inhibitor”, British Journal of Cancer volume103, pages 1554-1561 (9 Nov. 2010), which teaches the treatment ofcancer patients with CP-868,596 (crenolanib) in combination with ataxane and the VEGF pathway inhibitor axitinib (AG-013736). Thecombination of crenolanib and axitinib, a VEGFR TKI, along withdocetaxel chemotherapy was evaluated in a phase Ib study in patientswith relapsed or refractory advanced solid tumors [1]. Tumor typesrepresented in this study that received triplet therapy includednon-small cell lung cancer, prostate cancer, oesophageal carcinoma andother solid tumors. Approximately half of these patients had received ≥2prior chemotherapy regimens. In total, 48 patients in 4 differentcohorts were treated: Cohort 1 (7 patients): Crenolanib 60 mg BID plusdocetaxel 75 mg/m2; Cohort 2 (25 patients): Crenolanib 100 mg BID plusdocetaxel 75 mg/m2; Cohort 3 (7 patients): Crenolanib 100 mg BID plusdocetaxel 100 mg/m2; and Cohort 4 (9 patients): Crenolanib 60 mg BIDplus docetaxel 75 mg/m2 plus axitinib 5 mg BID. Patients in Cohort 4 whoreceived the triple combination therapy appeared to have an improvedoutcome compared to patients who received crenolanib with docetaxelalone. Eight of the nine patients (89%) that received the triplecombination therapy achieved stable disease (SD) for at least 4½ months,including 1 patient with EG adenocarcinoma; while only 11 of 39 patients(28%) that received only crenolanib plus docetaxel achieved SD.Toxicities of this triplet combination included the known toxicities ofeach individual agent but also included more mucositis-like symptoms andneutropenia than would have been expected relative to docetaxel alone.As such, the dose of crenolanib was not increased to 100 mg BID, asoriginally intended. Although toxicities can only be approximately andqualitatively assessed in such a small group, the development ofunanticipated toxicities led to the discontinuation of the planned doseescalation and an end to the treatments.

In an earlier study from the same authors, Michael, et al., “Phase Ibstudy of CP-868,596, a PDGFR inhibitor, in combination with docetaxel(Doc) with or without AG-013736, a VEGF inhibitor” Journal of ClinicalOncology 2008 26:15_suppl, 3549-3549, the authors previously foundsignificant side-effects from the use of crenolanib and AG-013736(axitinib) included nausea, diarrhea, vomiting, anemia, lethargy,stomatitis, neutropenia, anorexia, peripheral edema and hypertension.

Thus, a need remains for the treatment of cancers with multiplemutations, cancers that become resistant to first line therapies, and/orcancer therapies in which side effects are lessened or reduced.

SUMMARY OF THE INVENTION

In one embodiment, the present invention includes a method for treatinga proliferative disorder comprising administering to a subject atherapeutically effective amount of crenolanib or salt thereof incombination with a Vascular endothelial growth factor (VEGF), a Vascularendothelial growth factor receptor (VEGFR), or both (hereinafter the useof the individual agent alone, or in combination, is referred to asVEGF/VEGFR) inhibitor that is not axitinib sufficient to treat theproliferative disorder. In one aspect, the proliferative disorder is atleast one of: biliary tract cancer, bladder cancer, breast cancer,cervical cancer, CNS cancer, colon cancer, colorectal carcinoma,esophageal cancer, gastric cancer, gastroesophageal junction (GEJ)adenocarcinoma, gastric adenocarcinoma, stage IIIB gastricadenocarcinoma, stage IV invasive gastric adenocarcinoma, metastaticesophageal adenocarcinoma, glioblastoma, head and neck cancer,hepatocellular carcinoma, liver cancer, lung cancer, melanoma, non-smallcell cancer, nasopharyngeal cancer, neuroendocrine cancer, ovariancancer, pancreatic cancer, prostate cancer, renal cancer, salivary glandcancer, small cell cancer lung cancer, squamous cell cancer, skincancer, stomach cancer, testicular cancer, thyroid cancer, uterinecancer, or other solid tumors. In another aspect, the therapeuticallyeffective amount of crenolanib is from about 50 mg to 500 mg per day,100 to 450 mg per day, 200 to 400 mg per day, 300 to 500 mg per day 350to 500 mg per day, or 400 to 500 mg per day. In another aspect, thetherapeutically effective amount of crenolanib is administered at leastone of continuously, intermittently, systemically, or locally. Inanother aspect, the therapeutically effective amount of crenolanib isadministered orally, intravenously, or intraperitoneally, andadministered up to three times a day for as long as the subject is inneed for the treatment of the proliferative disease, which is a time ortreatment sufficient to treat the proliferative disease. In anotheraspect, the crenolanib is crenolanib besylate, crenolanib phosphate,crenolanib lactate, crenolanib hydrochloride, crenolanib citrate,crenolanib acetate, crenolanib toluenesulphonate, and crenolanibsuccinate. In another aspect, the method of further comprising providingthe subject with a chemotherapeutic agent that comprises one or more ofalkylating agents, antimetabolites, natural products, or a combinationthereof. In another aspect, the chemotherapeutic agent is an alkylatingagent that comprises one or more of carmustine, chlorambucil,cyclophosphamide, ifosfamide, lomustine, streptozotocin, temozolomide,cisplatin, carboplatin, nedaplatin, or oxaliplatin. In another aspect,the alkylating agent therapeutically effective amount is from about 22mg to 40 mg every 6 weeks, 150 to 200 mg every 6 weeks, 4 to 20 mg perday for 3 to 6 weeks, 2,000 to 4,750 given over 5 days, 4 to 19 mg perday, 1.44 to 3.12 g per day for 5 days in 3 weeks, 150 to 340 mg every 6weeks, 600 to 1,300 mg per day for 5 days within 6 weeks, 90 to 390 mgdaily, 24 to 260 mg per day for 5 days within 6 weeks, 240 to 1,690 mgevery 6 weeks, 72 to 234 mg every 4 weeks 78 to 221 mg every 2 weeks. Inanother aspect, the therapeutically effective amount of the alkylatingagent is administered at least one of continuously, intermittently,systemically, or locally. In another aspect, the therapeuticallyeffective amount of the alkylating agent is administered orally,intravenously, subcutaneously, or intraperitoneally. In another aspect,the chemotherapeutic agent is an antimetabolite that comprises one ormore of methotrexate, pemetrexed, ralititrexed, fluorouracil,floxuridine, capcitabine, or gemcitabine. In another aspect, theantimetabolite therapeutically effective amount is from about 3.6 to 7.8mg, 12 to 1,300 mg, 600 to 1,300 mg on day 1 of 21-day cycles. Inanother aspect, the therapeutically effective amount of theantimetabolite is administered at least one of continuously,intermittently, systemically, or locally. In another aspect, thetherapeutically effective amount of the antimetabolite is administeredorally, intravenously, subcutaneously, or intraperitoneally. In anotheraspect, the chemotherapeutic agent is an anti-proliferative agent thatcomprises one or more of vinblastine, vinorelbine, vincristine,vindesine, vinflunine, paclitaxel, docetaxel, cabazitaxel, etoposide,teniposide, topotecan, irinotecan, doxorubicin, eiprubicin, valrubicin,mitoxantrone, bleomycin, estramustine, or mitomycin. In another aspect,the therapeutically effective amount of the chemotherapeutic agent isfrom about 0.48 mg to 3.7 mg, 7.2 mg to 28.9 mg, 30 mg to 78 mg, 96 mgto 455 mg, 72 mg to 260 mg, 400 mg to 760 mg every three weeks; 42 to260 mg given days 1, 3, 5 of 21 day cycle, 198 mg to 650 mg once weekly,0.9 mg to 3.9 mg daily for 5 days of 21 day cycle, 150 mg to 910 mgdaily for 5 days of 21 day cycle, 48 mg to 195 mg every 21 days, 90 mgto 312 mg once every 3 or 4 weeks, 800 mg once weekly every 6 weeks,14.4 mg to 36.4 mg every 21 days, 12.5 units to 47.5 units every 1 to 2weeks, 500 mg to 1,520 mg per day, 12 mg to 52 mg every 6 to 8 weeks. Inanother aspect, the therapeutically effective amount of thechemotherapeutic agent is administered at least one of continuously,intermittently, systemically, or locally. In another aspect, thetherapeutically effective amount of the chemotherapeutic agent isadministered orally, intravenously, subcutaneously, orintraperitoneally. In another aspect, the VEGF/VEGFR inhibitor that isnot axitinib comprises ramicurimab, bevacuzamab, ranizumab, aflibercept,HLX12, ziv-aflibercept, vanucizumab, TX16, UB-922, BEVZ92, BCD-021,BI695502, CHS-5217, JHL1149, FKB238, Abevmy, ONS1045, PF06439535, HD204,SB8, TAB008, RPH001, BP102, HLX04, CT-P16, IBI305, LY01008, Mvasi,apagin, ranibizumab, CHS-3351, PF582, Xlucane, FYB201, razumab,CHS-2020, FYB203, ABP-201, sevacizumab, brolucizumab, CSL346, faricimab,hPV19, TAB014, UB-924, VGX-100, VX70, STI-A0168, CVX-241, BI 836880,ABT-165, conbercept, MP0250, MP0260, angiocal, abicipar pegol,anlotinib, apatinib, altiratinib, vandetanib, linifanib, motesanib,necuparanib, HLX12, APX004, CDP791, HLX-06, IBI302, icrucumab, IMC-1C11,IMC-3C5, MSB0254, navicixizumab, tanibirumab, V-DOS47, cabozantib,brivanib, dovitinib lactate, famitinib, foretinib, fruquintinib,golvatinib, henatinib, ponatinib, lenvatinib, lucitanib, sorafenib,nintedanib, orantinib, pegdinetanib, cediranib, rivoceranib,midostaurin, sitravatinib, regorafenib, sunitinib, sulfatnib,tesevatinib, tivozanib, valatanib, or pazopanib. In another aspect, thetherapeutically effective amount of the VEGF/VEGFR inhibitor that is notaxitinib is from about 250 mg to 1,425 mg every two to three weeks, 400mg to 2,600 mg every two to three weeks, 40 mg to 475 mg every twoweeks. In another aspect, the therapeutically effective amount of theVEGF/VEGFR inhibitor that is not axitinib is administered at least oneof continuously, intermittently, systemically, or locally. In anotheraspect, the therapeutically effective amount of the VEGF/VEGFR inhibitorthat is not axitinib is administered orally, intravenously,subcutaneously, or intraperitoneally. In another aspect, thetherapeutically effective amount of at least one of crenolanib, apharmaceutical agent, and VEGF/VEGFR inhibitor that is not axitinib isadministered for as long as the subject needs treatment for theproliferative disease. In another aspect, the therapeutically effectiveamount is administered one or more times a day or more for as long asthe subject is in need of treatment for the proliferative disorder. Inanother aspect, the therapeutically effective amount of crenolanib isprovided in subject with a proliferative disorder. In another aspect,the subject is a patient with a new cancer or the cancer has progressedon at least one line of chemotherapy in the advanced setting.

In another embodiment, the present invention includes a method for dualinhibition of angiogenesis by inhibition of both PDGFR and VEGFRsignaling as treatment of a proliferative disorder in a subjectcomprising a therapeutically effective amount of a VEGF/VEGFR inhibitorthat is not axitinib, and crenolanib or pharmaceutically acceptable saltthereof, wherein the subject is a human subject. In one aspect, theproliferative disorder is at least one of: biliary tract cancer, bladdercancer, breast cancer, cervical cancer, CNS cancer, colon cancer,colorectal carcinoma, esophageal cancer, gastric cancer,gastroesophageal junction (GEJ) adenocarcinoma, gastric adenocarcinoma,stage IIIB gastric adenocarcinoma, stage IV invasive gastricadenocarcinoma, metastatic esophageal adenocarcinoma, glioblastoma, headand neck cancer, hepatocellular carcinoma, liver cancer, lung cancer,melanoma, non-small cell cancer, nasopharyngeal cancer, neuroendocrinecancer, ovarian cancer, pancreatic cancer, prostate cancer, renalcancer, salivary gland cancer, small cell cancer lung cancer, squamouscell cancer, skin cancer, stomach cancer, testicular cancer, thyroidcancer, uterine cancer, or other solid tumors. In another aspect, thetherapeutically effective amount is from about 50 mg to 500 mg per day,100 to 450 mg per day, 200 to 400 mg per day, 300 to 500 mg per day 350to 500 mg per day, or 400 to 500 mg per day. In another aspect, themethod further comprises a pharmaceutical agent, that can be achemotherapeutic agent, that comprises one or more of paclitaxel,docetaxel, 5-fluorouracil, irinotecan, leucovorin calcium, oxaliplatin,capecitabine, interferon alpha, temozolomide, carboplatin, pegylatedliposomal doxorubicin, topotecan, cisplatin, pemetrexed or a combinationthereof. In another aspect, the VEGF/VEGFR inhibitor that is notaxitinib or AG-013736 comprises ramicurimab, bevacuzamab, ranizumab,aflibercept, HLX12, or ziv-aflibercept. In another aspect, theVEGF/VEGFR inhibitor that is not axitinib therapeutically effectiveamount is from about 250 mg to 1,425 mg every two to three weeks, 400 mgto 2,600 mg every two to three weeks, 40 mg to 475 mg every two weeks.In another aspect, the therapeutically effective amount of theVEGF/VEGFR inhibitor that is not axitinib is administered at least oneof continuously, intermittently, systemically, or locally. In anotheraspect, the therapeutically effective amount of the VEGF/VEGFR inhibitorthat is not axitinib is administered orally, intravenously,subcutaneously, or intraperitoneally. In another aspect, thetherapeutically or prophylactically effective amount of at least one ofcrenolanib, the pharmaceutical agent, and VEGF/VEGFR inhibitor that isnot axitinib is administered to keep the subject in a state of stabledisease or to cause a partial response, or complete response for as longas the subject needs such for the proliferative disease. In anotheraspect, the therapeutically effective amount of crenolanib isadministered at least one of continuously, intermittently, systemically,or locally. In another aspect, the therapeutically effective amount ofcrenolanib is administered orally, intravenously, or intraperitoneally,and administered up to three times a day for as long as the subject isin need for the treatment of the proliferative disease. In anotheraspect, the crenolanib is crenolanib besylate, crenolanib phosphate,crenolanib lactate, crenolanib hydrochloride, crenolanib citrate,crenolanib acetate, crenolanib toluenesulphonate, or crenolanibsuccinate. In another aspect, the therapeutically effective amount ofthe pharmaceutical agent is administered at least one of continuously,intermittently, systemically, or locally. In another aspect, thetherapeutically effective amount of the pharmaceutical agent isadministered orally, intravenously, subcutaneously, orintraperitoneally. In another aspect, the cancer is not non-small celllung cancer, small cell lung cancer, prostate, esophageal carcinoma,Ewing's sarcoma, or colorectal cancer. In another aspect, the dualinhibition of angiogenesis by inhibition of both PDGFR and VEGFRsignaling is synergistic. In another aspect, the proliferative disorderis resistant to FOLFOX chemotherapy. In another aspect, the compositionhas reduced side-effects when compared to a composition that includesaxitinib.

In another embodiment, the present invention includes a pharmaceuticalcomposition for the treatment of cancer in a human subject comprising:crenolanib or salt thereof, a VEGF/VEGFR inhibitor that is not axitinibin a therapeutically effective amount for the treatment of the cancer.In another aspect, the cancer is at least one of: biliary tract cancer,bladder cancer, breast cancer, cervical cancer, CNS cancer, coloncancer, colorectal carcinoma, esophageal cancer, gastric cancer,gastroesophageal junction (GEJ) adenocarcinoma, gastric adenocarcinoma,stage IIIB gastric adenocarcinoma, stage IV invasive gastricadenocarcinoma, metastatic esophageal adenocarcinoma, glioblastoma, headand neck cancer, hepatocellular carcinoma, liver cancer, lung cancer,melanoma, non-small cell cancer, nasopharyngeal cancer, neuroendocrinecancer, ovarian cancer, pancreatic cancer, prostate cancer, renalcancer, salivary gland cancer, small cell cancer lung cancer, squamouscell cancer, skin cancer, stomach cancer, testicular cancer, thyroidcancer, uterine cancer, or other solid tumors. In another aspect, thetherapeutically effective amount of crenolanib is from about 50 mg to500 mg per day, 100 to 450 mg per day, 200 to 400 mg per day, 300 to 500mg per day 350 to 500 mg per day, or 400 to 500 mg per day. In anotheraspect, the therapeutically effective amount of crenolanib isadministered at least one of continuously, intermittently, systemically,or locally. In another aspect, the therapeutically effective amount ofcrenolanib is administered orally, intravenously, or intraperitoneally,and administered up to three times a day for as long as the subject isin need for the treatment of the proliferative disease. In anotheraspect, the crenolanib is crenolanib besylate, crenolanib phosphate,crenolanib lactate, crenolanib hydrochloride, crenolanib citrate,crenolanib acetate, crenolanib toluenesulphonate, and crenolanibsuccinate. In another aspect, the composition further comprises achemotherapeutic agent selected from at least one of: one or morealkylating agents, one or more antimetabolites, or a combinationthereof. In another aspect, the chemotherapeutic agent is an alkylatingagent that comprises one or more of carmustine, chlorambucil,cyclophosphamide, ifosfamide, lomustine, streptozotocin, temozolomide,cisplatin, carboplatin, nedaplatin, or oxaliplatin. In another aspect,the alkylating agent therapeutically effective amount is from about 22mg to 40 mg every 6 weeks, 150 to 200 mg every 6 weeks, 4 to 20 mg perday for 3 to 6 weeks, 2,000 to 4,750 given over 5 days, 4 to 19 mg perday, 1.44 to 3.12 g per day for 5 days in 3 weeks, 150 to 340 mg every 6weeks, 600 to 1,300 mg per day for 5 days within 6 weeks, 90 to 390 mgdaily, 24 to 260 mg per day for 5 days within 6 weeks, 240 to 1,690 mgevery 6 weeks, 72 to 234 mg every 4 weeks 78 to 221 mg every 2 weeks. Inanother aspect, the chemotherapeutic agent is an antimetabolite thatcomprises one or more of methotrexate, pemetrexed, ralititrexed,fluorouracil, floxuridine, capcitabine, or gemcitabine. In anotheraspect, the antimetabolite therapeutically effective amount is fromabout 3.6 to 7.8 mg, 12 to 1,300 mg, 600 to 1,300 mg on day 1 of 21-daycycles. In another aspect, the chemotherapeutic agent is ananti-proliferative agent that comprises one or more of vinblastine,vinorelbine, vincristine, vindesine, vinflunine, paclitaxel, docetaxel,cabazitaxel, etoposide, teniposide, topotecan, irinotecan, doxorubicin,eiprubicin, valrubicin, mitoxantrone, bleomycin, estramustine, ormitomycin. In another aspect, the therapeutically effective amount ofthe chemotherapeutic agent is from about 0.48 mg to 3.7 mg, 7.2 mg to28.9 mg, 30 mg to 78 mg, 96 mg to 455 mg, 72 mg to 260 mg, 400 mg to 760mg every three weeks; 42 to 260 mg given days 1, 3, 5 of 21 day cycle,198 mg to 650 mg once weekly, 0.9 mg to 3.9 mg daily for 5 days of 21day cycle, 150 mg to 910 mg daily for 5 days of 21 day cycle, 48 mg to195 mg every 21 days, 90 mg to 312 mg once every 3 or 4 weeks, 800 mgonce weekly every 6 weeks, 14.4 mg to 36.4 mg every 21 days, 12.5 unitsto 47.5 units every 1 to 2 weeks, 500 mg to 1,520 mg per day, 12 mg to52 mg every 6 to 8 weeks. In another aspect, the VEGF/VEGFR inhibitorthat is not axitinib comprises ramicurimab, bevacuzamab, ranizumab,aflibercept, HLX12, ziv-aflibercept, vanucizumab, TX16, UB-922, BEVZ92,BCD-021, BI695502, CHS-5217, JHL1149, FKB238, Abevmy, ONS1045,PF06439535, HD204, SB8, TAB008, RPH001, BP102, HLX04, CT-P16, IBI305,LY01008, Mvasi, apagin, ranibizumab, CHS-3351, PF582, Xlucane, FYB201,razumab, CHS-2020, FYB203, ABP-201, sevacizumab, brolucizumab, CSL346,faricimab, hPV19, TAB014, UB-924, VGX-100, VX70, STI-A0168, CVX-241, BI836880, ABT-165, conbercept, MP0250, MP0260, angiocal, abicipar pegol,anlotinib, apatinib, altiratinib, vandetanib, linifanib, motesanib,necuparanib, HLX12, APX004, CDP791, HLX-06, IBI302, icrucumab, IMC-1C11,IMC-3C5, MSB0254, navicixizumab, tanibirumab, V-DOS47, cabozantib,brivanib, dovitinib lactate, famitinib, foretinib, fruquintinib,golvatinib, henatinib, ponatinib, lenvatinib, lucitanib, sorafenib,nintedanib, orantinib, pegdinetanib, cediranib, rivoceranib,midostaurin, sitravatinib, regorafenib, sunitinib, sulfatnib,tesevatinib, tivozanib, valatanib, or pazopanib. In another aspect, thetherapeutically effective amount of the VEGF/VEGFR inhibitor that is notaxitinib is from about 250 mg to 1,425 mg every two to three weeks, 400mg to 2,600 mg every two to three weeks, 40 mg to 475 mg every twoweeks.

BRIEF DESCRIPTION OF THE DRAWINGS

For a more complete understanding of the features and advantages of thepresent invention, reference is now made to the detailed description ofthe invention along with the accompanying figures and in which:

FIG. 1 shows the impact of the present invention on the progression freesurvival (PFS) of patients with gastroesophageal cancer. The clinicalcourse for each patient is detailed in the “Example”. Each patient wasadministered crenolanib besylate at a therapeutically effectiveconcentration in combination with a VEGF signaling pathway inhibitor anda chemotherapeutic agent as second-line treatment. The length of time,in months, to disease progression was recorded. The median PFS for thestandard of care for second-line gastric cancer (ramucirumab pluspaclitaxel) is indicated by the dashed line (4.4 months). The PFS inmonths and fold-change improvement over standard of care for eachpatient is indicated. One patient, Example 3, remains on study as ofDecember 2019.

FIG. 2 shows the impact of the present invention on the overall survival(OS) of patients with gastroesophageal cancer. The clinical course foreach patient is detailed in the “Example” section. Each patient wasadministered crenolanib besylate at a therapeutically effectiveconcentration in combination with a VEGF signaling pathway inhibitor anda chemotherapeutic agent as second-line treatment. The length of time,in months, to death was recorded. The median OS for the standard of carefor second-line gastric cancer (ramucirumab plus paclitaxel) isindicated by the dashed line (9.6 months). The OS in months andfold-change improvement over standard of care for each patient isindicated. Three patients, Example 1, Example 3, and Example 5 remainalive as of December 2019 (indicated by “*”).

DETAILED DESCRIPTION OF THE INVENTION

While the making and using of various embodiments of the presentinvention are discussed in detail below, it should be appreciated thatthe present invention provides many applicable inventive concepts thatcan be embodied in a wide variety of specific contexts. The specificembodiments discussed herein are merely illustrative of specific ways tomake and use the invention and do not delimit the scope of theinvention.

To facilitate the understanding of this invention, a number of terms aredefined below. Terms defined herein have meanings as commonly understoodby a person of ordinary skill in the areas relevant to the presentinvention. Terms such as “a”, “an” and “the” are not intended to referto only a singular entity but include the general class of which aspecific example may be used for illustration. The terminology herein isused to describe specific embodiments of the invention, but their usagedoes not delimit the invention, except as outlined in the claims.

Definitions

As used herein, the term “subject” refers to an animal, such as a mammalor a human, who has been the object of treatment, observation orexperiment.

As used herein, the term “therapeutically effective amount”, refers toan amount of crenolanib or a pharmaceutical salt thereof, an antiVEGF/VEGFR inhibitor that is not axitinib, and/or a pharmaceuticalagent, e.g., a chemotherapeutic agent, that in combination elicits thebiological or medicinal response in a subject that is being sought by aresearcher, veterinarian, medical doctor, or other clinician, whichincludes alleviation of the symptoms of the disease or disorder beingtreated. Methods for determining therapeutically effective doses forpharmaceutical compositions comprising a compound of the presentinvention are known in the art. Techniques and compositions for makinguseful dosage forms using the present invention are described in manyreferences, including: P. O. Anderson, J. E. Knoben, and W. G. Troutman,Handbook of clinical drug data, 10th ed. New York; Toronto: McGraw-HillMedical Pub. Division, 2002, pp. xvii, 1148 p; A. Goldstein, W. B.Pratt, and P. Taylor, Principles of drug action: the basis ofpharmacology, 3rd ed. New York: Churchill Livingstone, 1990, pp. xiii,836 p.; B. G. Katzung, Basic & clinical pharmacology, 9th ed. (Langemedical book). New York: Lange Medical Books/McGraw Hill, 2004, pp. xiv,1202 p.; L. S. Goodman, J. G. Hardman, L. E. Limbird, and A. G. Gilman,Goodman and Gilman's the pharmacological basis of therapeutics, 10th ed.New York: McGraw-Hill, 2001, pp. xxvii, 2148 p.; J. P. Remington and A.R. Gennaro, Remington: the science and practice of pharmacy, 20th ed.Baltimore, Md.: Lippincott Williams & Wilkins, 2000, pp. xv, 2077 p.; W.Martindale, J. E. F. Reynolds, and Royal Pharmaceutical Society of GreatBritain. Council, The extra pharmacopoeia, 31st ed. London: RoyalPharmaceutical Society, 1996, pp. xxi, 2739 p.; and G. M. Wilkes,Oncology Nursing Drug Handbook 2016, 20 ed. Sudbury: Jones & BartlettPublishers, 2016, p. 1500 p., relevant portions of each are incorporatedherein by reference. As used herein, the phrase “in combination with”refers to the administration of crenolanib or a pharmaceuticallyacceptable salt thereof, an anti-VEGFR/VEGF inhibitor that is notaxitinib, and in some instances a chemotherapeutic agent eithersimultaneously or sequentially in any order, such as, for example, atrepeated intervals as during a standard course of treatment for a singlecycle or more than one cycle, such that one agent can be administeredprior to, at the same time, or subsequent to the administration of theother agents, or any combination thereof. In one example, thecomposition includes crenolanib or a pharmaceutically acceptable saltthereof, ramicurimab, and paclitaxel in amounts sufficient for thetreatment of a disease.

As used herein, the term “composition” refers to a product comprisingthe specified ingredients in the specified amounts, as well as anyproduct that results, directly or indirectly, from combinations of thespecified ingredients in the specified amounts.

As used herein, the term “antibody” is used in the broadest sense andincludes various antibody structures, including but not limited tomonoclonal antibodies, polyclonal antibodies, multispecific antibodies(i.e., bispecific antibodies), and antibody fragments as long as theystill exhibit desired antigen-binding ability.

As used herein, the terms “proliferative disorder(s)” and “cellproliferative disorder(s)” refer to excess cell proliferation of one ormore subset of cells in a multicellular organism resulting in harm (i.e.discomfort or decreased life expectancy) to the multicellular organism.Cell proliferative disorders can occur in different types of animals andhumans. As used herein, “cell proliferative disorders” includeneoplastic disorders.

As used herein, the term “neoplastic disorder” refers to a tumorresulting from abnormal or uncontrolled cellular growth. Examples ofneoplastic disorders include, but are not limited to the followingdisorders, for instance: cancers such as carcinoma, lymphoma, blastoma,sarcoma, and leukemias. Non-limiting examples of proliferative disordersfor treatment with the present invention include biliary tract cancer,bladder cancer, breast cancer, cervical cancer, CNS cancer, coloncancer, colorectal carcinoma, esophageal cancer, gastric cancer,gastroesophageal junction (GEJ) adenocarcinoma, gastric adenocarcinoma,stage IIIB gastric adenocarcinoma, stage IV invasive gastricadenocarcinoma, metastatic esophageal adenocarcinoma, glioblastoma, headand neck cancer, hepatocellular carcinoma, liver cancer, lung cancer,melanoma, non-small cell cancer, nasopharyngeal cancer, neuroendocrinecancer, ovarian cancer, pancreatic cancer, prostate cancer, renalcancer, salivary gland cancer, small cell cancer lung cancer, squamouscell cancer, skin cancer, stomach cancer, testicular cancer, thyroidcancer, uterine cancer, or other solid tumors. In certain embodiments,the present invention is directed at the use of a pharmaceuticalcomposition comprising a pharmaceutical agent, VEGF/VEGFR inhibitor thatis not axitinib, and crenolanib or a pharmaceutically acceptable saltthereof in an amount sufficient for the treatment of a neoplasticdisorder, e.g., gastric cancer.

As used herein, the term “pharmaceutical agent” is used herein to referto one or more active agents that may be used in conjunction with thecomposition of crenolanib (or salts thereof) and a VEGF/VEGFR antagonistthat are not anti-mitotic or anti-proliferative per se, but that may beused in conjunction to activate the immune system to targetproliferative diseases or disorders, such as, e.g., cytokines,lymphokines, and the like.

As used herein, the term “chemotherapeutic agent” refers to anti-cellproliferation therapies such as alkylating agents, antimetabolites, andnatural products. Chemotherapy is known to those skilled in the art andthe appropriate dosage(s) and scheme(s) for chemotherapy will be similarto those already employed in clinical therapies wherein the chemotherapyis delivered in combination with other therapies or used alone. Avariety of chemotherapeutic agents may be used in combination with thepresent invention. By way of example only, taxane compounds (such asdocetaxel), are safely administered in combination in the compound ofthe present invention in a dosage of 75 mg per square meter (mg/m²) ofbody surface area. The skilled artisan will recognize that the selectedchemotherapeutic will have a dosage based on a variety of factors, suchas the weight, age, gender, extent of disease, etc., that will changethe dosage within best medical practice for the intended treatment.

As used herein, the term “alkylating agent” refers to a group ofchemotherapies that classically have caused the addition of an alkylgroup to DNA but is now used to refer to any chemotherapy that causesaddition of a small chemical moiety to DNA. Examples of alkylatingagents include, but are not limited to carmustine, chlorambucil,cyclophosphamide, ifosfamide, lomustine, streptozotocin, temozolomide,cisplatin, carboplatin, nedaplatin, oxaliplatin.

As used herein, the term “antimetabolite” refers to a group ofchemotherapies that structurally similar to a naturally occurringchemical in the body that it can take the place of said chemical inbinding to an enzyme or protein but are different enough that theyprohibit the termination of the normal action of the chemical in thebody. Examples of antimetabolites include, but are not limited tomethotrexate, pemetrexed, ralititrexed, fluorouracil, floxuridine,capcitabine, gemcitabine.

As used herein, the term “natural products” refers to a group ofchemotherapeutic agents and/or chemotherapies that are purified organiccompounds originally isolated from a living organism that are producedby pathways of secondary metabolism. Examples of natural productsincludes but is not limited to vinblastine, vinorelbine, vincristine,vindesine, vinflunine, paclitaxel, docetaxel, cabazitaxel, etoposide,teniposide, topotecan, irinotecan, doxorubicin, eiprubicin, valrubicin,mitoxantrone, bleomycin, estramustine, mitomycin.

Unfortunately, the use of axitinib (a small molecule tyrosine kinaseinhibitor) to target VEGFR, has significant side effects, including:thromboembolic (both venous and arterial) events; hemorrhagic events(including cerebral hemorrhage), hypertension, gastrointestinalperforations and fistula, changes in thyroid function, clotting factorinhibition, proteinuria, elevated liver enzymes (AST, ALT andbilirubin), and loss of hepatic function, leading to the need todecrease dosing, and thus, effectiveness, leading to an end of the studyand the failure to increase dosing. Combinatorial approach to fullinhibition of angiogenesis by block both VEGFR and PDGFR signaling.

The present invention comprises the combination of a generalpharmaceutical agent, a VEGF/VEGFR antibody, and crenolanib(4-Piperidinamine, 1-[2-[5-[(3-methyl-3-oxetanyl)methoxy]-1H-benzimidazol-1-yl]-8-quinolinyl]) and its pharmaceuticallyacceptable salts, as a method for reducing or inhibiting tumor growthwhile simultaneously inhibition angiogenesis by blocking bothendothelial cells (by blocking VEGFR signaling) and pericytes (byblocking PDGFRB signaling) in a subject. Examples of VEGF/VEGFRinhibitors include those that block the activation of VEGFR by bindingto VEGF, affect the expression of VEGF or VEGFR, affect downstreamsignaling from VEGFR, and the like. Examples of VEGF/VEGFR inhibitorsthat are not axitinib comprise: ramicurimab, bevacuzamab, ranizumab,aflibercept, HLX12, ziv-aflibercept, vanucizumab, TX16, UB-922, BEVZ92,BCD-021, B1695502, CHS-5217, JHL1149, FKB238, Abevmy, ONS1045,PF06439535, HD204, SB8, TAB008, RPH001, BP102, HLX04, CT-P16, IB1305,LY01008, Mvasi, apagin, ranibizumab, CHS-3351, PF582, Xlucane, FYB201,razumab, CHS-2020, FYB203, ABP-201, sevacizumab, brolucizumab, CSL346,faricimab, hPV19, TAB014, UB-924, VGX-100, VX70, STI-A0168, CVX-241, BI836880, ABT-165, conbercept, MP0250, MP0260, angiocal, abicipar pegol,anlotinib, apatinib, altiratinib, vandetanib, linifanib, motesanib,necuparanib, HLX12, APX004, CDP791, HLX-06, IB1302, icrucumab, IMC-1C11,IMC-3C5, MSB0254, navicixizumab, tanibirumab, V-DOS47, cabozantib,brivanib, dovitinib lactate, famitinib, foretinib, fruquintinib,golvatinib, henatinib, ponatinib, lenvatinib, lucitanib, sorafenib,nintedanib, orantinib, pegdinetanib, cediranib, rivoceranib,midostaurin, sitravatinib, regorafenib, sunitinib, sulfatnib,tesevatinib, tivozanib, valatanib, or pazopanib.

Crenolanib has the formula:

Crenolanib can exist in a variety of salt forms, including but notlimited to: Crenolanib Besylate, Crenolanib Phosphate, CrenolanibLactate, Crenolanib Hydrochloride, Crenolanib Citrate, CrenolanibAcetate, Crenolanib Toluenesulphonate and Crenolanib Succinate, but mayalso be made available free of salts. Preparation of the compounds ofthe present invention. General synthetic methods for preparing thecompounds of Formula I are provided in, e.g., U.S. Pat. No. 5,990,146(issued Nov. 23, 1999) (Warner-Lambert Co.) and PCT publishedapplication numbers WO 99/16755 (published Apr. 8, 1999) (Merck & Co.)WO 01/40217 (published Jul. 7, 2001) (Pfizer, Inc.), US PatentApplication Publication No. US 2005/0124599 (Pfizer, Inc.) and U.S. Pat.No. 7,183,414 (Pfizer, Inc.), relevant portions incorporated herein byreference.

By way of example, Crenolanib besylate is an orally bioavailable,selective, and potent type I TKI of class III receptor tyrosine kinases(RTKs). The chemical name of crenolanib besylate is 4-piperidinamine,1-[2-[5-[(3-methyl-3-oxetanyl)methoxy]-1H-benzimidazol-1-yl]-8-quinolinyl]-, monobenzenesulfonate. Thecompound has the ability to inhibit PDGFR-α and PDGFR-β. Crenolanib doesnot inhibit any other known RTKs (e.g., VEGFR or fibroblast growthfactor receptor) or serine/threonine kinases (e.g., Abl, Raf) atconcentrations that are used clinically.

Angiogenesis is a complex biological process that requires a variety offactors and signaling pathways to stimulate the migration andproliferation of the component cell types, and to establish functionalblood vessels. Angiogenesis is driven by pro-angiogenic factors likevascular endothelial growth factor (VEGF) that forms new capillarynetworks. PDGF activation of PDGFR-α is responsible for the migration ofsupporting pericytes to support and stabilize angiogenesis [2, 3].Inhibitors of VEGF, such as Avastin (bevacizumab), have been approved inmultiple different types of cancer, including colorectal, non-small celllung, ovarian, cervical, renal cell carcinoma, and glioblastoma (GBM).Bevacizumab only has single agent activity in ovarian cancer (trials).Bevacizumab in combination with chemotherapy has seen improvements inPFS in metastatic 1st line breast cancer, metastatic 1st and 2nd linecolorectal cancer, metastatic 1st line NSCLC, metastatic 1st and 2ndline ovarian cancer, metastatic 1st line prostate cancer, and metastatic1st line renal cancer [4-17]. Ramucirumab is an antibody against VEGFreceptor 2 (VEGFR2), was evaluated in two different phase III clinicaltrials (RAINBOW and REGARD), which led to its approval alone or incombination with paclitaxel in gastric cancer, non-small cell lungcancer, and colorectal cancer. Another antibody against VEGF,aflibercept, also blocks VEGF binding to its receptor and is approvedfor use in wet macular degeneration and metastatic colorectal cancer.These VEGF inhibitors have provided crucial evidence highlighting therole and significance of targeting angiogenesis across multiple solidtumors [18-20]. Ramucirumab has also been evaluated in the treatment ofcolorectal cancer and non-small cell lung carcinoma. In a Phase IIIstudy of ramucirumab in combination with chemotherapy in metastaticcolorectal cancer (RAISE), patients treated with ramucirumab andchemotherapy had modestly increased overall survival (OS; 13.3 versus11.7 months) and progression-free survival (PFS; 5.7 versus 4.5 months)over patients treated with placebo and chemotherapy. The improvedresults seen in this trial supported the granting of marketingauthorization for ramucirumab in metastatic colorectal cancer [21].Ramucirumab has also been granted marketing approval in the setting ofnon-small cell lung cancer (NSCLC). In a Phase III clinical trialevaluating the efficacy of ramucirumab in combination with docetaxelversus placebo with docetaxel (REVEL), patients treated with ramucirumabhad increased OS (11.2 versus 9.8 months) [22]. As with the results ofthe RAINBOW study, virtually all patients in both the RAISE and REVELtrials eventually developed disease progression. These modest resultsdemonstrate the existence of underlying and acquired mechanisms ofresistance to VEGF-pathway inhibition.

Despite the incremental benefit of a VEGF/VEGFR antibody andchemotherapy, 13% of patients in the RAINBOW study experiencedprogressive disease (PD) as their best response and virtually allpatients eventually developed progression. In addition, ramucirumabmonotherapy is associated with a response rate (RR) of only 3% and aprogression-free survival (PFS) improvement of only 0.8 months overplacebo.

The susceptibility of established tumor blood vessels to interferencewith VEGF/VEGFR-2 signaling may be restricted to a fraction of immaturevessels that lack co-localization with pericytes [3]. Pericytes arebelieved to be either generated by in situ differentiation frommesenchymal cells or by migration and de-differentiation of arterialsmooth muscle cells. Contact between endothelial cells andperi-endothelial support cells such as pericytes stabilizes new bloodvessels and promotes endothelial survival. Blood vessels in manyexperimental and human tumor types are closely associated withpericytes, allowing these tumors to survive targeting the VEGF pathwayalone. Additional targeting of pericyte recruitment andpericyte/endothelial cell interaction may enhance tumor vesseldestruction after interference with VEGF/VEGFR-2 signaling. ThePDGF/PDGFR pathway has been implicated in the maintenance ofinterstitial pressure.

One of the postulated mechanisms of resistance to anti-VEGF therapy isupregulation of signaling through the PDGF/PDGFR pathway. Theplatelet-derived growth factors (PDGF-A, PDGF-B, PDGF-C, and PDGF-D) orligands in their monomeric form are inactive and linked by amino aciddisulfide bonds to form active one homodimeric and four heterodimericisoforms: PDGF-AA, PDGF-BB, PDGF-CC, PDGF-DD, and PDGF-AB. Theseisoforms exert their biological effects on either homodimeric PDGFR-ααor PDGFR-ββ or heterodimeric PDGFR-αβ receptors through specificbinding, resulting in their activation. Oncogenic alteration of PDGFRand overexpression of PDGF ligands and receptors contributes totumorigenesis. Cancers in which PDGFR is altered include pancreatic,ovarian, breast, gastric, thymoma, gastrointestinal stromal tumor,osteosarcoma, and hepatocellular carcinoma. For example, data over thelast decade has provided strong clinical and pre-clinical significanceof the role of anti-angiogenesis in gastric cancer and critical roleplayed by PDGFR-β in angiogenesis. There is also evidence that showshigh PDGF-D expression is strongly associated with tumor progression,recurrence, distant metastasis, and poor outcomes in patients withgastric cancer, further highlighting the crucial role PDGF and PDGFRplay in cancer and the urgent need to target this pathway [23].

In a mouse model, Erber et al., demonstrated that treatment of implantedtumors with an anti-VEGFR TKI, SU5416, failed to induce regression ofestablished blood vessels, although it suppressed furtherneovascularization and, therefore, prevented tumor growth [24]. Theunderlying mechanism of resistance arose from the recruitment ofpericytes to stabilize the tumor blood vessels. PDGFR-β expression bypericytes and endothelial cells also doubled. Subsequently, theydemonstrated that dual inhibition with a TKI with activity against bothVEGFR and PDGFR, SU6668, resulted in regression of established tumorvessels, leading to an increase in microvascular permeability andmicrovascular hemorrhage. This led to decreased oxygenation in the tumortissue, endothelial cell apoptosis and suppression of tumor growth.Although PDGFR-β expression was elevated and comparable to theSU5416-treated tumors, the association of pericytes with endothelialcells was less intimate than in the SU5416-treated tumors, suggestingthat PDGFR inhibition may exert its effects at this level [24].

PDGFR inhibitors known in the art include but are not limited toavapritinib (also known as Blu-285, Blueprint Medicines Corp.); CBT-102(CBT Pharmaceuticals); dovitinib lactate (also known as CHIR-258,Oncology Venture A/S); Gleevec (also known as Glivec, imatinib, NovartisAG); E7050 (also known as golvatinib, Eisai, Co., Ltd.); Latruvo (alsoknown as olaratumab, Eli Lily & Co.); Lenvima (also known as lenvatinib,E7080, Eisai, Co., Ltd.); Lucitanib (also known as AL3810, ClovisOncology, Inc.); macitinib (also known as AB1010, AB Science A. B.);Nexavar (also known as sorafenib, Amgen, Inc.); Ofev (also known asnintedanib, BIBF-1120, Boehringer Ingelheim GmbH); PDGF-BB (Adocia SAS);Regranex (also known as becalpermin, Novartis AG); Stivarga (also knownas regorafenib, Bayer AG); Sutent (also known as sunitinib, Pfizer,Inc.); Tasigna (also known as nilotinib, AMN107, Novartis AG); telatinib(also known as BAY 57-9352, Eddingpharm); Votrient (also known aspazopanib, Novartis AG); X-82 (Xcovery, Inc.).

These PDGFR inhibitors have either been or are currently beinginvestigated in the preclinical setting, phase I, phase II, or phase IIItrials as monotherapy or combination studies in relapsed or refractorytumors. In most patients, the clinical response is short-lived, andpatients experience adverse side effects. End study response criteriafor patients treated with PDGFR inhibitor includes a partial tumorresponse and an increase in delay time to progression. To effectivelytreat treatment-resistant cancers, especially those that are resistantto anti-angiogenesis agents, and overcome the significant unmet need inthis patient population, an inhibitor that significantly abrogatesPDGF/PDGFR signaling can help decrease relapse rates and increaseoverall survival in early stage disease patients. The current inventionseeks to overcome disadvantages of the prior art.

Tumor interstitial pressure. An additional mechanism of chemotherapyresistance that has been postulated is the high interstitial pressurewithin tumors, which results in a lower hydrostatic gradient from thevasculature to the interstitium and reduced passage of solutes,including chemotherapy drugs, across the capillary membrane into thetumor [25].

It has previously been hypothesized that anti-angiogenic drugs such asbevacizumab, an antibody against VEGF-A, may function in part bynormalizing the tumor vasculature, reducing the tumor interstitialpressure and thereby increase chemotherapy delivery into the tumor. Thisfunction is somewhat related but distinct from the proposed role ofanti-angiogenic therapy in inhibiting neovascularization and wouldexplain the lack of single-agent activity of bevacizumab—andramucirumab.

The PDGF-PDGFR pathway has been implicated in the maintenance ofinterstitial pressure and there are also data that anti-PDGFR therapiescan reduce interstitial pressures. Imatinib, which has activity againstthe PDFGR-β tyrosine kinase, has been shown in a rat model to decreaseinterstitial hypertension and to increase the capillary-to-interstitiumtransport of solutes [26]. In another series of experiments by the samegroup, treatment with imatinib resulted in increased anti-tumor effectof paclitaxel and increased paclitaxel uptake by the tumors [27].

The present invention is based on the novel observation that acombination of inhibition of PDGF and VEGF/VEGFR (with an inhibitor thatis not axitinib) and chemotherapeutic agents significantly improvesoutcomes for patients with cancer.

The present inventors recognize for the first time synergy between PDGFand VEGF inhibition. As such, there is a rationale and basis tocombining PDGF and VEGF pathway inhibitors with cytotoxic chemotherapybut to also strongly consider alternative agents.

In summary, crenolanib is generally well tolerated as a single agent andwhen combined with chemotherapy; the most common adverse events aregastrointestinal toxicities, elevations in liver enzymes and bilirubin,and edema/effusions. Unlike axitinib, VEGF/VEGFR antibodies areassociated with minimal toxicity and the combination of these antibodiesand chemotherapy is very well-tolerated [4-19, 21, 22, 28-32]. Inparticular, axinitinib monotherapy (in renal cancer patients) isassociated with notable toxicities, including all-grade fatigue,anorexia, nausea, diarrhea and hand-foot syndrome in >25% ofpatients[33]. Additionally, paclitaxel is less myelosuppressive thandocetaxel. These improved toxicities support the combination ofcrenolanib and an alternative VEGFR inhibitor (including ramucirumab) inaddition to and chemotherapy in patients with advanced cancers.

In one embodiment to this aspect, the present invention provides amethod for reducing or debulking the tumor while simultaneouslyinhibiting angiogenesis by blocking not only VEGF signaling whichinhibits the growth and migration of endothelial cells, but also byblocking PDGF signaling which inhibits the growth and migration ofpericytes which stabilize newly formed or forming blood vessels in asubject comprising the step of administering the compounds of thepresent invention to the subject, wherein the combination is provided atleast one of sequentially or simultaneously.

In other embodiments, the present invention provides therapeutic methodsfor treating a subject with a cell proliferative disorder driven byabnormal new vasculature formation. In one example, the inventionprovides methods for treating a cell proliferative disorder that isdependent on recruitment and growth of new vasculature to support tumorgrowth, comprising administration of a therapeutically effective amountof a pharmaceutical composition comprising the compounds of the presentinvention in a subject. Administration of the therapeutic agents canoccur upon manifestation of symptoms characteristic of the cellproliferative disorder, such that a disease or disorder is treated.

The present disclosure discloses a method for treating a subject with acell proliferative disorder that is dependent on recruitment of newblood vasculature for the sustainment and growth of said proliferativedisorder. In one example, the invention provides methods for treating aproliferative disorder comprising administration of a therapeuticallyeffective amount of a pharmaceutical composition comprising apharmaceutical agent, VEGF/VEGFR inhibitor that is not axitinib, andcrenolanib in a subject. Administration of the present invention canoccur upon manifestation of symptoms characteristic of a solid tumorcell proliferative disorder, such that a disease or disorder treated.

A main advantage of the combination treatments of the invention is theability of producing marked anti-tumor effects in a patient withoutcausing significant toxicities or adverse events, so that the patientbenefits from the combination treatment method overall. The efficacy ofthe combination treatment of the invention can be measured by manyendpoints commonly used to evaluate cancer treatments, including but notlimited to, tumor regression, tumor size shrinkage, time to progression,overall survival, and quality of life. Because the invention related tothe use of a combination of unique anti-tumor agents, novel approachesfor determining efficacy or any particular part of the combinationtherapy of the present invention can be employed, including for example,measurement of biomarkers of VEGF and/or PDGF signaling, such asVEGF-AB, or PDGF, and measurement of response through radiologicalimaging.

In one embodiment of the present invention, the chemotherapeutic agent,anti-VEGF/VEGFR inhibitor that is not axitinib, and crenolanib or apharmaceutically acceptable salt thereof may be administered to asubject systemically, for example, orally, intravenously,subcutaneously, intramuscular, intradermal or parenterally. Thecompounds of the present invention can also be administered to a subjectlocally.

Compounds of the present invention may be formulated for slow-release orfast-release with the objective of maintaining contact of compounds ofthe present invention with targeted tissues for a desired range of time.

Compositions suitable for oral administration include solid forms, suchas pills, tablets, caplets, capsules, granules, and powders, liquidforms, such as solutions, emulsions, and suspensions. Forms useful forparenteral administration include sterile solutions, emulsions andsuspensions.

The daily dosage of the compounds of the present invention may be variedover a wide range from 50 to 500 mg per adult human per day. For oraladministration, the compositions are preferably provided in the form oftablets containing 20 and 100 milligrams. The compounds of the presentinvention may be administered on a regimen up to three times or more perday. Preferably three times per day. Optimal doses to be administeredmay be determined by those skilled in the art and will vary with thecompound of the present invention used, the mode of administration, thetime of administration, the strength of the preparation, and the detailsof the disease condition. Factors associated with patientcharacteristics, such as age, weight, and diet will call for dosageadjustments.

Preparation of the compounds of the present invention. General syntheticmethods, which may be referred to for preparing the compounds of formulaI are provided in U.S. Pat. No. 5,990,146 (issued Nov. 23, 1999)(Warner-Lambert Co.) and PCT published application numbers WO 99/16755(published Apr. 8, 1999) (Merck & Co.) WO 01/40217 (published Jul. 7,2001) (Pfizer, Inc.), US Patent Application No. US 2005/0124599 (Pfizer,Inc.) and U.S. Pat. No. 7,183,414 (Pfizer, Inc.), relevant portionsincorporated herein by reference.

Pharmaceutically acceptable salts such as hydrochloride, phosphate andlactate are prepared in a manner similar to the benzenesulfonate saltand are well known to those of moderate skill in the art. The followingrepresentative compounds of the present invention are for exemplarypurposes only and are in no way meant to limit the invention, includingCrenolanib as Crenolanib Besylate, Crenolanib Phosphate, CrenolanibLactate, Crenolanib Hydrochloride, Crenolanib Citrate, CrenolanibAcetate, Crenolanib Toluenesulphonate and Crenolanib Succinate.

EXAMPLE 1

Effect of crenolanib besylate combination therapy in a gastroesophagealjunction (GEJ) adenocarcinoma patient with metastases in the liver:Partial Response per RECIST 1.1 criteria.

A 53-year-old male was initially diagnosed September 2017 withesophageal cancer. The patient was treated with palliative FOLFOXchemotherapy: a combination of a fluoropyrimidine (fluorouracil, or5-FU), a platinum compound (oxaliplatin), and leucovorin. Palliativechemotherapy began late September 2017 and continued until January 2018.Oral capecitabine was then given to the patient for 5 months until thepatient's cancer progressed June 2018 when a CT scan revealed that thepatient had progressive disease and the cancer had metastasized to theliver, upper stomach, and lymph nodes.

In response to progression on first-line therapy, the patient wasprovided oral crenolanib besylate (PDGFRβ inhibitor) in combination withpaclitaxel and ramucirumab (VEGFR2 inhibitor) on a clinical trial forsecond-line advanced esophagogastric adenocarcinoma (NCT03193918). Atbaseline, the patient had a sum of diameters of 112 mm, per RECIST 1.1criteria. After 8 weeks on combination treatment, the patient achievedstable disease (SD) per RECIST 1.1 criteria with a decrease in sum ofdiameters to 76 mm. After 16 weeks on treatment, the patient achieved apartial response (PR) per RECIST 1.1 criteria with a 40% decrease in sumof diameters from baseline. After an additional 8 weeks on treatment,the patient achieved a total decrease of 57% in sum of diameters frombaseline. On crenolanib therapy, this patient had a progression-freesurvival (PFS) of 7.8 months. This is a significant improvement over thePFS of 4.4 months observed with paclitaxel plus ramucirumab, which isthe standard of care in second-line gastric cancer at the time offiling. [19]

EXAMPLE 2

Effect of crenolanib besylate combination therapy in a stage IIIB,gastric adenocarcinoma patient with metastatic disease to lymph nodes:Partial Response per RECIST 1.1 criteria.

A 68-year-old female was diagnosed September 2015 with stage IIIBmetastatic cancer in the stomach and lymph nodes. She underwent apartial gastrectomy and started adjuvant FOLFOX chemotherapy October2015. She remained on the FOLFOX regimen for 12 cycles until April 2016.Despite adjuvant chemotherapy treatment, a CAT scan October 2016 showedincreased metastatic disease in the lymph node, which promptedpalliative chemotherapy with fluorouracil. The patient continued toprogress and was found to have metastatic disease to the gastrohepaticligament, lungs, and lymph nodes in October 2017.

In response to progression on first-line therapy, the patient wasprovided oral crenolanib besylate (PDGFRβ inhibitor) in combination withpaclitaxel and ramucirumab (VEGFR2 inhibitor) on a clinical trial forsecond-line advanced esophagogastric adenocarcinoma (NCT03193918). Atbaseline, the patient had a sum of diameters of 35 mm, per RECIST 1.1criteria. After only 8 weeks on combination treatment, the patientachieved a PR per RECIST 1.1 criteria with a decrease in sum ofdiameters to 21 mm. The patient maintained a PR in follow-up CTassessments and remained on crenolanib besylate, ramucirumab, andpaclitaxel combination treatment for 22 weeks. The patient achieved a5.5-month PFS while on crenolanib besylate combination treatment, animprovement over current standard of care in second-line gastric cancer.

EXAMPLE 3

Effect of crenolanib besylate combination therapy in a stage IV,invasive gastric adenocarcinoma patient: Stable Disease per RECIST 1.1criteria.

A 50-year-old male was diagnosed with invasive gastric cancer in May2016. The tumor was found to arise from Helicobacter pylori (H.pylori)-associated chronic gastritis. The patient was treated withneoadjuvant FOLFOX chemotherapy. After 12 cycles of FOLFOX chemotherapy,the patient underwent a partial gastrectomy and lymphadenectomy inNovember 2018. Despite 6 months of neoadjuvant chemotherapy and asurgical approach, a follow-up CT scan and laparoscopy in April 2018revealed the cancer had metastasized to the ileum and peritoneum.

In response to progression on first-line therapy, the patient wasprovided oral crenolanib besylate (PDGFRβ inhibitor) in combination withpaclitaxel and ramucirumab (VEGFR2 inhibitor) on a clinical trial forsecond-line advanced esophagogastric adenocarcinoma (NCT03193918). Atbaseline, the CT scan from May 2018 revealed a sum of diameters of 28mm, per RECIST 1.1 criteria. After 80 weeks of crenolanib besylatecombination therapy, the patient has maintained SD, per RECIST 1.1criteria. As of early December 2019, the patient remains on trial withan approximate PFS of 18.5 months and is clinically stable. Thispatient's PFS is over four times longer than that observed with currentstandard of care and demonstrates the benefit and utility of the presentinvention.

EXAMPLE 4

Effect of crenolanib besylate combination therapy in a metastaticesophageal adenocarcinoma with extensive mediastinal and upper abdominallymph node metastases: Stable Disease per RECIST 1.1 criteria.

A 32-year-old male was initially diagnosed with metastatic cancer in theesophagus and lymph nodes in October 2016. He was started on FOLFOXchemotherapy, a combination of a fluoropyrimidine (fluorouracil, or5-FU) and a platinum compound (oxaliplatin) and remained on FOLFOX for 3months. The patient remained on a fluoropyrimidine until May 2017 andwas given another platinum compound (cisplatin) for approximately 2months from early April 2017 to the end of May 2017. Despite thecombination of a fluoropyrimidine and 2 separate platinum compounds, thepatient progressed June 2017 when a CT scan revealed increased diseasein the lymph nodes and metastatic disease to stomach and liver.

In response to progression on first-line therapy, the patient wasprovided oral crenolanib besylate (PDGFRβ inhibitor) in combination withpaclitaxel and ramucirumab (VEGFR2 inhibitor) on a clinical trial forsecond-line advanced esophagogastric adenocarcinoma (NCT03193918). Atbaseline, the CT scan from June 2017 revealed a sum of diameters of 49mm, per RECIST 1.1 criteria. After 8 weeks on combination treatment,patient achieved SD, per RECIST 1.1, with a decrease in sum of diametersto 42 mm. The patient achieved a PFS of 6.6 months while on crenolanibbesylate combination treatment, which is a significant improvement overstandard of care.

EXAMPLE 5

Effect of crenolanib besylate in a metastatic gastric adenocarcinoma:Stable Disease per RECIST 1.1 criteria.

A 72-year-old male was initially diagnosed August 2015 with gastricadenocarcinoma. The patient was treated with surgery and neoadjuvantFOLFOX chemotherapy. After surgery, the patient received maintenance5-fluorouracil until July 2018, when a CT scan revealed the patient hadprogressive disease and worsening peritoneal carcinomatosis.

In response to progression on first-line therapy, the patient wasprovided oral crenolanib besylate (PDGFRβ inhibitor) in combination withpaclitaxel and ramucirumab (VEGFR2 inhibitor) on a clinical trial forsecond-line advanced esophagogastric adenocarcinoma (NCT03193918). Atbaseline, the patient had a sum of diameters of 68 mm, per RECIST 1.1criteria. The patient maintained clinically stable disease for 28 weekswhile on crenolanib treatment, per RECIST 1.1 criteria. The patientachieved a PFS of over 7 months on crenolanib besylate combinationtreatment, a significant improvement over the standard of care oframucirumab plus paclitaxel.

The basic information, including PFS and survival, for the aboveexamples are displayed in Table 1 (examples of partial response totreatment) and Table 2 (examples of stable disease). For all examples,the PFS was significantly longer than that seen on paclitaxel plusramucirumab, the standard of care treatment for second-line gastriccancer. This improvement in PFS can be readily seen in FIG. 1 , whichshows the PFS observed for each patient on crenolanib besylatecombination therapy, as well as a reference (dashed line) of the medianPFS observed with standard of care. In addition to significantlyimproved PFS, the present invention also extended the overall survival(OS) for these examples (FIG. 2 ). The median OS seen with paclitaxelplus ramucirumab treatment was 9.6 months.[19] The examples describedherein all survived for 14 months or more, with three examples (1, 3,and 5) remaining alive as of December 2019 (indicated as a “+” in thesurvival column of Tables 1 and 2 and denoted with “*” in FIG. 2 ).

TABLE 1 shows the basic characteristics and clinical course ofsecond-line gastroesophageal cancer patients treated with the presentinvention who achieved a Partial Response to crenolanib besylatecombination therapy. Both patients achieved >40% shrinkage of theirtumors, with Example 1 achieving 57% shrinkage. Also listed is theprogression-free survival (PFS) and overall survival (OS) for eachpatient. Patient Example 1 remains alive as of December 2019, asindicated by the “+” in the survival column.

TABLE 1 Partial Response Summary Data from Gastroesophageal CancerPatients Treated with Crenolanib Besylate Combination Therapy Examples -Partial Response to Crenolanib Combination Treatment Site of PrimaryPrevious Tumor PFS Survival Example Age Sex Tumor Chemotherapy Shrinkage(months) (months) 1 53 M Esophageal FOLFOX 57% 7.8 15+ 2 68 F GastricFOLFOX 40% 5.5 24 

TABLE 2 shows the basic characteristics and clinical course ofsecond-line gastroesophageal cancer patients treated with the presentinvention who maintained Stable Disease while on crenolanib besylatecombination therapy. All three patients remained clinically stable forat least 6 months, and one patient “Example 3” remains on-study, and iscurrently receiving crenolanib besylate combination treatment, as ofDecember 2019. Also listed is the OS for each patient. Two patients,Example 3 and Example 5, remain alive as of December 2019, as indicatedby the “+” in the survival column.

TABLE 2 Stable Disease Summary Data from Gastroesophageal CancerPatients Treated with Crenolanib Besylate Combination Therapy.Examples - Stable Disease on Crenolanib Combination Treatment Site ofPrimary Previous PFS Survival Example Age Sex Tumor Chemotherapy(months) (months) 3 50 M Gastric FOLFOX 18.5+ On-study 4 32 M EsophagealFOLFOX 6.6 20  5 72 M Gastric FOLFOX 7 14+

From the above examples, it is evident to those skilled in the art thatthe present invention is of significant benefit to patients showingstatistically significant improvement outcomes as compared to standardof care. The additive benefit of crenolanib besylate is of anunexpectedly significant magnitude, especially when skilled artisansconsider that the improvement of the addition of ramucirumab topaclitaxel resulted in only a 52% improvement in PFS and a 30%improvement in OS, compared to the median 72% improvement in PFS and 93%improvement in OS seen with the present invention.[19] In addition,there is not a significant expectation of success as responses toanti-angiogenic therapy of the prior art, including ramucirumab, are atbest transient, with most patient progressing on treatment.[19] In fact,in general, the impact of anti-angiogenesis agents on survival, astaught in the prior art [34], has been disappointing. This history of,at best, modest and transient results of targeted angiogenesis agents,either as single agent therapy or in combination with chemotherapy,highlights the unexpected utility and benefit of the present invention.

It is contemplated that any embodiment discussed in this specificationcan be implemented with respect to any method, kit, reagent, orcomposition of the invention, and vice versa. Furthermore, compositionsof the invention can be used to achieve methods of the invention.

It will be understood that particular embodiments described herein areshown by way of illustration and not as limitations of the invention.The principal features of this invention can be employed in variousembodiments without departing from the scope of the invention. Thoseskilled in the art will recognize, or be able to ascertain using no morethan routine experimentation, numerous equivalents to the specificprocedures described herein. Such equivalents are considered to bewithin the scope of this invention and are covered by the claims.

All publications and patent applications mentioned in the specificationare indicative of the level of skill of those skilled in the art towhich this invention pertains. All publications and patent applicationsare herein incorporated by reference to the same extent as if eachindividual publication or patent application was specifically andindividually indicated to be incorporated by reference.

The use of the word “a” or “an” when used in conjunction with the term“comprising” in the claims and/or the specification may mean “one,” butit is also consistent with the meaning of “one or more,” “at least one,”and “one or more than one.” The use of the term “or” in the claims isused to mean “and/or” unless explicitly indicated to refer toalternatives only or the alternatives are mutually exclusive, althoughthe disclosure supports a definition that refers to only alternativesand “and/or.” Throughout this application, the term “about” is used toindicate that a value includes the inherent variation of error for thedevice, the method being employed to determine the value, or thevariation that exists among the study subjects.

As used in this specification and claim(s), the words “comprising” (andany form of comprising, such as “comprise” and “comprises”), “having”(and any form of having, such as “have” and “has”), “including” (and anyform of including, such as “includes” and “include”) or “containing”(and any form of containing, such as “contains” and “contain”) areinclusive or open-ended and do not exclude additional, unrecitedelements or method steps. In embodiments of any of the compositions andmethods provided herein, “comprising” may be replaced with “consistingessentially of” or “consisting of”. As used herein, the phrase“consisting essentially of” requires the specified integer(s) or stepsas well as those that do not materially affect the character or functionof the claimed invention. As used herein, the term “consisting” is usedto indicate the presence of the recited integer (e.g., a feature, anelement, a characteristic, a property, a method/process step or alimitation) or group of integers (e.g., feature(s), element(s),characteristic(s), property(ies), method/process steps or limitation(s))only.

The term “or combinations thereof” as used herein refers to allpermutations and combinations of the listed items preceding the term.For example, “A, B, C, or combinations thereof” is intended to includeat least one of: A, B, C, AB, AC, BC, or ABC, and if order is importantin a particular context, also BA, CA, CB, CBA, BCA, ACB, BAC, or CAB.Continuing with this example, expressly included are combinations thatcontain repeats of one or more item or term, such as BB, AAA, AB, BBC,AAABCCCC, CBBAAA, CABABB, and so forth. The skilled artisan willunderstand that typically there is no limit on the number of items orterms in any combination, unless otherwise apparent from the context.

As used herein, words of approximation such as, without limitation,“about”, “substantial” or “substantially” refers to a condition thatwhen so modified is understood to not necessarily be absolute or perfectbut would be considered close enough to those of ordinary skill in theart to warrant designating the condition as being present. The extent towhich the description may vary will depend on how great a change can beinstituted and still have one of ordinary skill in the art recognize themodified feature as still having the required characteristics andcapabilities of the unmodified feature. In general, but subject to thepreceding discussion, a numerical value herein that is modified by aword of approximation such as “about” may vary from the stated value byat least ±1, 2, 3, 4, 5, 6, 7, 10, 12 or 15%.

All of the compositions and/or methods disclosed and claimed herein canbe made and executed without undue experimentation in light of thepresent disclosure. While the compositions and methods of this inventionhave been described in terms of preferred embodiments, it will beapparent to those of skill in the art that variations may be applied tothe compositions and/or methods and in the steps or in the sequence ofsteps of the method described herein without departing from the concept,spirit and scope of the invention. All such similar substitutes andmodifications apparent to those skilled in the art are deemed to bewithin the spirit, scope and concept of the invention as defined by theappended claims.

To aid the Patent Office, and any readers of any patent issued on thisapplication in interpreting the claims appended hereto, applicants wishto note that they do not intend any of the appended claims to invokeparagraph 6 of 35 U.S.C. § 112, U.S.C. § 112 paragraph (f), orequivalent, as it exists on the date of filing hereof unless the words“means for” or “step for” are explicitly used in the particular claim.

For each of the claims, each dependent claim can depend both from theindependent claim and from each of the prior dependent claims for eachand every claim so long as the prior claim provides a proper antecedentbasis for a claim term or element.

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What is claimed is:
 1. A method for treating a proliferative disorder comprising administering to a subject a therapeutically effective amount of crenolanib or salt thereof in combination with a vascular endothelial growth factor (VEGF), a vascular endothelial growth factor receptor (VEGFR), or both (VEGF/VEGFR) inhibitor that is not axitinib sufficient to treat the proliferative disorder.
 2. The method of claim 1, wherein the proliferative disorder is at least one of: biliary tract cancer, bladder cancer, breast cancer, cervical cancer, CNS cancer, colon cancer, colorectal carcinoma, esophageal cancer, gastric cancer, gastroesophageal junction (GEJ) adenocarcinoma, gastric adenocarcinoma, stage IIIB gastric adenocarcinoma, stage IV invasive gastric adenocarcinoma, metastatic esophageal adenocarcinoma, glioblastoma, head and neck cancer, hepatocellular carcinoma, liver cancer, lung cancer, melanoma, non-small cell cancer, nasopharyngeal cancer, neuroendocrine cancer, ovarian cancer, pancreatic cancer, prostate cancer, renal cancer, salivary gland cancer, small cell cancer lung cancer, squamous cell cancer, skin cancer, stomach cancer, testicular cancer, thyroid cancer, thymoma, uterine cancer, or other tumors.
 3. The method of claim 1, wherein the therapeutically effective amount of crenolanib or a salt thereof is from about 50 mg to 500 mg per day, 100 to 450 mg per day, 200 to 400 mg per day, 300 to 500 mg per day 350 to 500 mg per day, or 400 to 500 mg per day.
 4. The method of claim 1, wherein the therapeutically effective amount of crenolanib or salt thereof, the VEGF/VEGFR inhibitor, or both, is administered at least one of continuously, intermittently, systemically, or locally.
 5. The method of claim 1, wherein the therapeutically effective amount of crenolanib or salt thereof, the VEGF/VEGFR inhibitor, or both, is administered orally, intravenously, or intraperitoneally.
 6. The method of claim 1, wherein crenolanib is crenolanib besylate, crenolanib phosphate, crenolanib lactate, crenolanib hydrochloride, crenolanib citrate, crenolanib acetate, crenolanib toluenesulphonate, and crenolanib succinate.
 7. The method of claim 1, further comprising providing the subject a chemotherapeutic agent that comprises one or more of alkylating agents, antimetabolites, natural products, or a combination thereof.
 8. The method of claim 7, wherein the chemotherapeutic agent is provided in a therapeutically effective amount and is selected from: an alkylating agent that comprises one or more of carmustine, chlorambucil, cyclophosphamide, ifosfamide, lomustine, streptozotocin, temozolomide, cisplatin, carboplatin, nedaplatin, or oxaliplatin; an anti-proliferative agent that comprises one or more of vinblastine, vinorelbine, vincristine, vindesine, vinflunine, paclitaxel, docetaxel, cabazitaxel, etoposide, teniposide, topotecan, irinotecan, doxorubicin, eiprubicin, valrubicin, mitoxantrone, bleomycin, estramustine, or mitomycin; or an antimetabolite that comprises one or more of methotrexate, pemetrexed, ralititrexed, fluorouracil, floxuridine, capcitabine, or gemcitabine.
 9. The method of claim 8, wherein a therapeutically effective amount of the alkylating agent is from about 22 mg to 40 mg every 6 weeks, 150 to 200 mg every 6 weeks, 4 to 20 mg per day for 3 to 6 weeks, 2,000 to 4,750 given over 5 days, 4 to 19 mg per day, 1.44 to 3.12 g per day for 5 days in 3 weeks, 150 to 340 mg every 6 weeks, 600 to 1,300 mg per day for 5 days within 6 weeks, 90 to 390 mg daily, 24 to 260 mg per day for 5 days within 6 weeks, 240 to 1,690 mg every 6 weeks, 72 to 234 mg every 4 weeks 78 to 221 mg every 2 weeks.
 10. The method of claim 8, wherein a therapeutically effective amount of the antimetabolite is from about 3.6 to 7.8 mg, 12 to 1,300 mg, 600 to 1,300 mg on day 1 of 21-day cycles.
 11. The method of claim 8, wherein the therapeutically effective amount of the chemotherapeutic agent is administered at least one of continuously, intermittently, systemically, or locally.
 12. The method of claim 8, wherein the therapeutically effective amount of the chemotherapeutic agent is from about 0.48 mg to 3.7 mg, 7.2 mg to 28.9 mg, 30 mg to 78 mg, 96 mg to 455 mg, 72 mg to 260 mg, 400 mg to 760 mg every three weeks; 42 to 260 mg given days 1, 3, 5 of 21 day cycle, 198 mg to 650 mg once weekly, 0.9 mg to 3.9 mg daily for 5 days of 21 day cycle, 150 mg to 910 mg daily for 5 days of 21 day cycle, 48 mg to 195 mg every 21 days, 90 mg to 312 mg once every 3 or 4 weeks, 800 mg once weekly every 6 weeks, 14.4 mg to 36.4 mg every 21 days, 12.5 units to 47.5 units every 1 to 2 weeks, 500 mg to 1,520 mg per day, 12 mg to 52 mg every 6 to 8 weeks.
 13. The method of claim 1, wherein the VEGF/VEGFR inhibitor that is not axitinib is selected from at least one of: ramicurimab, bevacuzamab, ranizumab, aflibercept, HLX12, ziv-aflibercept, vanucizumab, TX16, UB-922, BEVZ92, BCD-021, BI695502, CHS-5217, JHL1149, FKB238, Abevmy, ONS1045, PF06439535, HD204, SB8, TAB008, RPH001, BP102, HLX04, CT-P16, IBI305, LY01008, Mvasi, apagin, ranibizumab, CHS-3351, PF582, Xlucane, FYB201, razumab, CHS-2020, FYB203, ABP-201, sevacizumab, brolucizumab, CSL346, faricimab, hPV19, TAB014, UB-924, VGX-100, VX70, STI-A0168, CVX-241, BI 836880, ABT-165, conbercept, MP0250, MP0260, angiocal, abicipar pegol, anlotinib, apatinib, altiratinib, vandetanib, linifanib, motesanib, necuparanib, HLX12, APX004, CDP791, HLX-06, IBI302, icrucumab, IMC-1C11, IMC-3C5, MSB0254, navicixizumab, tanibirumab, V-DOS47, cabozantib, brivanib, dovitinib lactate, famitinib, foretinib, fruquintinib, golvatinib, henatinib, ponatinib, lenvatinib, lucitanib, sorafenib, nintedanib, orantinib, pegdinetanib, cediranib, rivoceranib, midostaurin, sitravatinib, regorafenib, sunitinib, sulfatnib, tesevatinib, tivozanib, valatanib, or pazopanib.
 14. The method of claim 1, wherein the therapeutically effective amount of the VEGF/VEGFR inhibitor that is not axitinib is from about 250 mg to 1,425 mg every two to three weeks, 400 mg to 2,600 mg every two to three weeks, 40 mg to 475 mg every two weeks.
 15. The method of claim 1, wherein the therapeutically effective amount of crenolanib, VEGF/VEGFR inhibitor that is not axitinib and a pharmaceutical agent, are administered from at least one of: for as long as the subject needs treatment for the proliferative disorder; one or more times a day or more for as long as the subject is in need of treatment for the proliferative disorder; for a patient with a newly diagnosed proliferative disorder or the proliferative disorder has progressed on at least one line of chemotherapy in the advanced setting; or up to three times a day for as long as the subject is in need of treatment of the proliferative disorder.
 16. A method for dual inhibition of angiogenesis by inhibition of both PDGFR and VEGFR signaling as a treatment of a proliferative disorder in a subject comprising a composition comprising a therapeutically effective amount of a VEGF/VEGFR inhibitor that is not axitinib, and a therapeutically effective amount of crenolanib or pharmaceutically acceptable salt thereof, wherein the subject is a human subject.
 17. The method of claim 16, wherein the proliferative disorder is at least one of: biliary tract cancer, bladder cancer, breast cancer, cervical cancer, CNS cancer, colon cancer, colorectal carcinoma, esophageal cancer, gastric cancer, gastroesophageal junction (GEJ) adenocarcinoma, gastric adenocarcinoma, stage IIIB gastric adenocarcinoma, stage IV invasive gastric adenocarcinoma, metastatic esophageal adenocarcinoma, glioblastoma, head and neck cancer, hepatocellular carcinoma, liver cancer, lung cancer, melanoma, non-small cell cancer, nasopharyngeal cancer, neuroendocrine cancer, ovarian cancer, pancreatic cancer, prostate cancer, renal cancer, salivary gland cancer, small cell cancer lung cancer, squamous cell cancer, skin cancer, stomach cancer, testicular cancer, thyroid cancer, thymoma, uterine cancer, or other tumors.
 18. The method of claim 16, wherein the therapeutically effective amount of crenolanib or a salt thereof is from about 50 mg to 500 mg per day, 100 to 450 mg per day, 200 to 400 mg per day, 300 to 500 mg per day 350 to 500 mg per day, or 400 to 500 mg per day.
 19. The method of claim 16, further comprising a pharmaceutical agent comprises one or more of paclitaxel, docetaxel, 5-fluorouracil, irinotecan, leucovorin calcium, oxaliplatin, capecitabine, interferon alpha, temozolomide, carboplatin, pegylated liposomal doxorubicin, topotecan, cisplatin, pemetrexed or a combination thereof.
 20. The method of claim 16, wherein the VEGF/VEGFR inhibitor that is not axitinib comprises ramicurimab, bevacuzamab, ranizumab, aflibercept, HLX12, ziv-aflibercept, vanucizumab, TX16, UB-922, BEVZ92, BCD-021, BI695502, CHS-5217, JHL1149, FKB238, Abevmy, ONS1045, PF06439535, HD204, SB8, TAB008, RPH001, BP102, HLX04, CT-P16, IBI305, LY01008, Mvasi, apagin, ranibizumab, CHS-3351, PF582, Xlucane, FYB201, razumab, CHS-2020, FYB203, ABP-201, sevacizumab, brolucizumab, CSL346, faricimab, hPV19, TAB014, UB-924, VGX-100, VX70, STI-A0168, CVX-241, BI 836880, ABT-165, conbercept, MP0250, MP0260, angiocal, abicipar pegol, anlotinib, apatinib, altiratinib, vandetanib, linifanib, motesanib, necuparanib, HLX12, APX004, CDP791, HLX-06, IBI302, icrucumab, IMC-1C11, IMC-3C5, MSB0254, navicixizumab, tanibirumab, V-DOS47, cabozantib, brivanib, dovitinib lactate, famitinib, foretinib, fruquintinib, golvatinib, henatinib, ponatinib, lenvatinib, lucitanib, sorafenib, nintedanib, orantinib, pegdinetanib, cediranib, rivoceranib, midostaurin, sitravatinib, regorafenib, sunitinib, sulfatnib, tesevatinib, tivozanib, valatanib, or pazopanib.
 21. The method of claim 16, wherein the VEGF/VEGFR inhibitor that is not axitinib therapeutically effective amount is from about 250 mg to 1,425 mg every two to three weeks, 400 mg to 2,600 mg every two to three weeks, 40 mg to 475 mg every two weeks.
 22. The method of claim 16, wherein the therapeutically effective amount of the crenolanib or a salt thereof, the VEGF/VEGFR inhibitor that is not axitinib, or both, is at least one of: administered at least one of continuously, intermittently, systemically, or locally; administered in an amount to keep the subject in a state of stable disease, or to cause a partial response, or complete response for as long as the subject needs such treatment for the proliferative disorder; or administered up to three times a day for as long as the subject is in need for the treatment of the proliferative disorder.
 23. The method of claim 16, wherein crenolanib is crenolanib besylate, crenolanib phosphate, crenolanib lactate, crenolanib hydrochloride, crenolanib citrate, crenolanib acetate, crenolanib toluenesulphonate, or crenolanib succinate.
 24. The method of claim 16, wherein the therapeutically effective amount of the composition is administered orally, intravenously, subcutaneously, or intraperitoneally.
 25. The method of claim 16, further comprising the step of determining if the proliferative disorder is resistant to folinic acid, fluorouracil and oxaliplatin (FOLFOX) chemotherapy.
 26. A pharmaceutical composition for treatment of a cancer in a human subject comprising: a crenolanib or salt thereof and a VEGF/VEGFR inhibitor that is not axitinib in a therapeutically effective amount for the treatment of the cancer.
 27. The pharmaceutical composition of claim 26, wherein the cancer is at least one of: biliary tract cancer, bladder cancer, breast cancer, cervical cancer, CNS cancer, colon cancer, colorectal carcinoma, esophageal cancer, gastric cancer, gastroesophageal junction (GEJ) adenocarcinoma, gastric adenocarcinoma, stage IIIB gastric adenocarcinoma, stage IV invasive gastric adenocarcinoma, metastatic esophageal adenocarcinoma, glioblastoma, head and neck cancer, hepatocellular carcinoma, liver cancer, lung cancer, melanoma, non-small cell cancer, nasopharyngeal cancer, neuroendocrine cancer, ovarian cancer, pancreatic cancer, prostate cancer, renal cancer, salivary gland cancer, small cell cancer lung cancer, squamous cell cancer, skin cancer, stomach cancer, testicular cancer, thyroid cancer, thymoma, uterine cancer, or other solid tumors.
 28. The pharmaceutical composition of claim 26, wherein a therapeutically effective amount of crenolanib is from about 50 mg to 500 mg per day, 100 to 450 mg per day, 200 to 400 mg per day, 300 to 500 mg per day 350 to 500 mg per day, or 400 to 500 mg per day.
 29. The pharmaceutical composition of claim 26, wherein a therapeutically effective amount of crenolanib is administered at least one of continuously, intermittently, systemically, or locally.
 30. The pharmaceutical composition of claim 26, wherein a therapeutically effective amount of crenolanib, VEGF/VEGFR inhibitor that is not axitinib, or both, is administered orally, intravenously, or intraperitoneally, and the therapeutically effective amount is administered up to three times a day for as long as a subject is in need of treatment of the cancer.
 31. The pharmaceutical composition of claim 26, wherein crenolanib is crenolanib besylate, crenolanib phosphate, crenolanib lactate, crenolanib hydrochloride, crenolanib citrate, crenolanib acetate, crenolanib toluenesulphonate, and crenolanib succinate.
 32. The pharmaceutical composition of claim 26, further comprising a chemotherapeutic agent in an amount effective to treat the cancer, wherein the chemotherapeutic agent is selected from at least one of: one or more alkylating agents, one or more antimetabolites, one or more anti-proliferative agents, or a combination thereof.
 33. The pharmaceutical composition of claim 32, wherein the chemotherapeutic agent is at least one of: an alkylating agent that comprises one or more of carmustine, chlorambucil, cyclophosphamide, ifosfamide, lomustine, streptozotocin, temozolomide, cisplatin, carboplatin, nedaplatin, or oxaliplatin; antimetabolite that comprises one or more of methotrexate, pemetrexed, ralititrexed, fluorouracil, floxuridine, capcitabine, or gemcitabine; or anti-proliferative agents that comprises one or more of vinblastine, vinorelbine, vincristine, vindesine, vinflunine, paclitaxel, docetaxel, cabazitaxel, etoposide, teniposide, topotecan, irinotecan, doxorubicin, eiprubicin, valrubicin, mitoxantrone, bleomycin, estramustine, or mitomycin.
 34. The pharmaceutical composition of claim 32, wherein a therapeutically effective amount of the alkylating agent is from about 22 mg to 40 mg every 6 weeks, 150 to 200 mg every 6 weeks, 4 to 20 mg per day for 3 to 6 weeks, 2,000 to 4,750 given over 5 days, 4 to 19 mg per day, 1.44 to 3.12 g per day for 5 days in 3 weeks, 150 to 340 mg every 6 weeks, 600 to 1,300 mg per day for 5 days within 6 weeks, 90 to 390 mg daily, 24 to 260 mg per day for 5 days within 6 weeks, 240 to 1,690 mg every 6 weeks, 72 to 234 mg every 4 weeks 78 to 221 mg every 2 weeks.
 35. The pharmaceutical composition of claim 32, wherein a therapeutically effective amount of the antimetabolite is from about 3.6 to 7.8 mg, 12 to 1,300 mg, 600 to 1,300 mg on day 1 of 21-day cycles.
 36. The pharmaceutical composition of claim 32, wherein the therapeutically effective amount of the chemotherapeutic agent is from about 0.48 mg to 3.7 mg, 7.2 mg to 28.9 mg, 30 mg to 78 mg, 96 mg to 455 mg, 72 mg to 260 mg, 400 mg to 760 mg every three weeks; 42 to 260 mg given days 1, 3, 5 of 21 day cycle, 198 mg to 650 mg once weekly, 0.9 mg to 3.9 mg daily for 5 days of 21 day cycle, 150 mg to 910 mg daily for 5 days of 21 day cycle, 48 mg to 195 mg every 21 days, 90 mg to 312 mg once every 3 or 4 weeks, 800 mg once weekly every 6 weeks, 14.4 mg to 36.4 mg every 21 days, 12.5 units to 47.5 units every 1 to 2 weeks, 500 mg to 1,520 mg per day, 12 mg to 52 mg every 6 to 8 weeks.
 37. The pharmaceutical composition of claim 26, wherein the VEGF/VEGFR inhibitor that is not axitinib comprises ramicurimab, bevacuzamab, ranizumab, aflibercept, HLX12, ziv-aflibercept, vanucizumab, TX16, UB-922, BEVZ92, BCD-021, B1695502, CHS-5217, JHL1149, FKB238, Abevmy, ONS1045, PF06439535, HD204, SB8, TAB008, RPH001, BP102, HLX04, CT-P16, D3I305, LY01008, Mvasi, apagin, ranibizumab, CHS-3351, PF582, Xlucane, FYB201, razumab, CHS-2020, FYB203, ABP-201, sevacizumab, brolucizumab, CSL346, faricimab, hPV19, TAB014, UB-924, VGX-100, VX70, STI-A0168, CVX-241, BI 836880, ABT-165, conbercept, MP0250, MP0260, angiocal, abicipar pegol, anlotinib, apatinib, altiratinib, vandetanib, linifanib, motesanib, necuparanib, HLX12, APX004, CDP791, HLX-06, IBI302, icrucumab, IMC-1C11, IMC-3C5, MSB0254, navicixizumab, tanibirumab, V-DOS47, cabozantib, brivanib, dovitinib lactate, famitinib, foretinib, fruquintinib, golvatinib, henatinib, ponatinib, lenvatinib, lucitanib, sorafenib, nintedanib, orantinib, pegdinetanib, cediranib, rivoceranib, midostaurin, sitravatinib, regorafenib, sunitinib, sulfatnib, tesevatinib, tivozanib, valatanib, or pazopanib.
 38. The pharmaceutical composition of claim 26, wherein the therapeutically effective amount of the VEGF/VEGFR inhibitor that is not axitinib is from about 250 mg to 1,425 mg every two to three weeks, 400 mg to 2,600 mg every two to three weeks, 40 mg to 475 mg every two weeks. 